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m
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onditionsPsychiatry and ‘The Rest of Medicine’
Psychiatry is obviously psychological, at first glance, but also obviously social, at second glance, while biological to a degree, while the rest of medicine—according to the biomedical model—manages well enough with the biological only. In this sense, the question of psychiatry’s rela-tion to ‘the rest of medicine’ stands proxy for the rarela-tionale and validity
of the biopsychosocial model—and vice versa. In fact, Engel chose just this issue as the starting place for his 1977 paper; he turned on its head the aspiration for psychiatry to emulate the rest of medicine, recom-mending the opposite: make the rest of medicine more like psychiatry—
more psychosocial, not biological only [4] (p. 129).
On the other hand, as we noted at the beginning of the first chap-ter (under the heading “The Presumed ‘Overarching framework’”), the ‘rest of medicine’ is not one thing, and the various medical speci-alities differ in their relative involvement with biological, psychological and social factors. Primary care (also known as general medical practice, or family medicine) is much involved with the psychosocial, as is public health, and palliative care, as well as many aspects of care on acute med-ical wards. In this sense, the contrast is not so much between psychiatry with the rest of medicine, but between psychiatry along with many other areas of medicine, contrasted with biomedicine. Taking these consider-ations things into account much qualifies the idea that psychiatry is so different because of its involvement with the psychosocial. Nevertheless, psychiatry can still be regarded as the odd one out compared with ‘the rest of medicine’, for reasons that go much deeper than detailed and dis-criminating considerations of the above sort about varying degrees of involvement with the psychosocial.
The Difference Is Deeply Theorised and Institutionalised
The perceived difference between mental and physical health condi-tions and healthcare is underpinned by the great historical dichotomies outlined in the first chapter, Sect. 1.3 (under the heading “Prejudicial Theory: Physicalism, Reductionism, Dualism”): mind/body dual-ism, and the separation of the social and moral sciences from the nat-ural sciences. Thomas Szasz’s highly influential 1960s critique of psychiatry [54] relied on these dichotomies. But worse, the two sides of the dichotomies were not equally balanced in respect of scientific validity, especially in connection with determining causes and interven-tions—matters fundamental to medicine. Rather, against the background of physicalist reductionism, which underpinned the dichotomies, as reviewed in Sect. 2.2, while physical health conditions involved recog-nised causes and effects, researchable and manageable by proper biologi-cal/biomedical science, mental disorders were something else altogether, barely recognisable let alone theorised, and psychiatry along with them.
Built on top of the historical dichotomies in deep theory are the rein-forcing, maintaining effects of having organised the whole of healthcare training and delivery around physical health problems on one side of the road and mental health problems on the other. On one side, bio-medicine performs best with biological mechanisms in physical diseases, and psychosocial involvement, if any, is out of scope. On the other side, theoretical or practical preoccupation with ‘mental abnormalities’ such as delusions and other hard to understand mental states and behaviour tends to neglect somatic signs and symptoms, and does not bring into focus people as a whole and their social circumstances. The dichotomy between mental and physical health conditions is historically theorised and currently institutionalised and practised.
The Biopsychosocial Model Highlights Similarities
There are several reasons why the picture is changing however. Mental health conditions are more evident, linked to increasing public aware-ness and efforts to decrease stigma, and the extent of associated activity impairments such as days lost to work is better understood and increas-ingly recognised as comparable with those in physical health conditions.
It is increasingly recognised that physical and mental health problems often co-occur, complicating each other, and therefore also complicating our healthcare system, given that it is currently organised on the basis of separating them out, along with the clinical expertise for managing them. And as regards aetiology, public health and prevention, recent epi-demiology suggests that the two kinds of health problem can share aetio-logical risk factors, possibly implicating shared mechanisms. These social and scientific developments change policy, as for example in the UK NHS policy paper ‘No health without mental health’ [55]. In this sec-tion, we review these issues in more detail, with reference to the biopsy-chosocial theory and science set out in previous chapters.
Considering aetiology, we noted in the first chapter, Sect. 1.2, the emerging epidemiological evidence that implicates psychosocial as well as biological risk factors including genetic for many physical health con-ditions. It also suggests that some risks of all sorts are shared between some physical health conditions and some mental health conditions; it is not the case that risk factors divide neatly into those to physical health on the one hand and those to mental health on the other. Drilling into hypothesised mechanisms, we saw in section Stress as a Biopsychosocial
Causal Mechanism that chronic stress and its biological effects are commonly implicated in the aetiology of many physical and mental health conditions. Again, it is not the case that pathogenic mechanisms neatly divide between those for physical health conditions and those for mental health conditions. As corollary, preventative strategies and tech-nologies, for many physical and mental health conditions, overlap. Public health does not have two unconnected tasks, one for physical health pro-motion and another for mental health propro-motion.
Post onset, especially for the long-term conditions, also considered in Sect. 1.2 under the heading “Emerging Evidence of Psychosocial Causation”, psychosocial factors affect biomedical management, in mat-ters such as access and collaboration over management plan, for example ongoing medication; as well as affecting psychological adjustment and quality of social life. These diverse psychosocial issues coincide or at least overlap for both physical health and mental health long term con-ditions. We went on to note the connected finding that physical health problems raise risk for mental health problems and vice versa. The causal pathways are diverse, but include such as chronic physical ill-health imposes activity restrictions and loss of amenity, and pain, all of which raise risk of high anxiety and low mood; mental health chronic condi-tions can be associated with risk factors for physical health problems, such as social exclusion, poor diet, smoking, and higher thresholds for medical attention to physical health problems. The picture that emerges, therefore, is not that of patients with physical health problems, and an entirely different set of patients with mental health problems. All these considerations—regarding aetiology, adjustment, quality of life, and bidi-rectional complications—serve to break down the dichotomy between mental health conditions and physical health conditions. They highlight the importance of psychological and social as well as biological factors in health and disease, and they need broad biopsychosocial theory to accommodate them.
The general drift of the biopsychosocial systemic approach—as can be expected from its name—is to view physical and mental health conditions under a unified ‘health problem’ heading. The core common feature is a substantial negative effect on the person’s agency, associated with dis-tress: with worry and fear about their safety and their future and their dependents.
In the broader biopsychosocial picture, the key secondary difference between physical health problems and health problems is that some but
not all physical health problems have a biomedically identifiable main-taining cause—a disease process or lesion—while this is probably not the case for mental health problems. This is a critical difference and it stands out most clearly for physical health problems that are biomedically well understood and treatable, in a relatively short timeframe, without therefore impacting on what is presupposed as an otherwise normal life.
Cure of infectious disease by antibiotics, surgical interventions that are now routine such as hip replacements and even cardiac surgery, especially where all the psychological and social conditions for access, detection and intervention are in place, and which therefore can be ignored, stand out as triumphs of biomedicine. If we start with the underlying presumption that physical health problems are purely physical—and entirely different from mental health problems—these are the cases we will attend to, and we would tend to neglect the kinds and aspects of physical health prob-lems that don’t fit the picture: regarding aetiology, chronic conditions and comorbidities as reviewed briefly above. And, coming from the other direction, the assumption that mental health problems are quite different from physical health problems because exclusively to do with the mind, or the person, is also problematic. for example, some mental health con-ditions have some response to pharmacotherapy. It is true that psycho-logical therapy is often indicated along with medication for mental health conditions, but equally, as is now being recognised, it is often indicated alongside medical management of physical health conditions [56]. As to mental health conditions, as opposed to physical health conditions, being integral to the personality, the contrast is less marked for long-term con-ditions of either type, as previously remarked in Sect. 4.2. Also, some mental health conditions such as obsessive-compulsive disorder are typ-ically seen by the person as externally imposed, rather than as integral to themselves. This is probably the rule for mental health conditions rather than the exception. This is a complicated clinical area but the point, in short, is that only for a particular sub-class of mental health conditions is there a strong presumed link with personality, that is, the so-called ‘per-sonality disorders’.
Another way of viewing the similarities and differences between men-tal health conditions and physical health conditions is through the lens of the hypothetical virtual biopsychosocial research framework sketched above (Sect. 4.3). In addition to the specification of biological and neu-rological systemic functioning, this framework was imagined to include specification of health problems, physical and mental, and to have
complete coverage of stages, from risks of onset through to post-on-set maintaining causal mechanisms, interventions, and factors affecting adjustment and quality-of-life in long-term conditions. The columns of the grid would include biological, psychological and social factors, and the cells research findings. The upshot of this is that the relative impor-tance of biological compared with psychosocial factors would be most marked between mental and some physical health problems at just one—
albeit very important—point, namely post-onset maintaining causal mechanisms and interventions. for some physical health problems, these would be mainly biological with little psychosocial. But for all other stages: aetiological pathways to onset, and post-onset adjustment and quality-of-life, the pattern of relative weights of biological, psychological and social would be evened out and would certainly not be all biological for all physical health problems, and all psychological and social for men-tal health problems.
4.5 l
ocatingtheb
ioPsychosocialm
odelWe noted in the first chapter that the biopsychosocial model has been charged with vagueness in the clinic, as well as vagueness as a scientific theory and as a ‘model’. It is true that Engel wrote his 1980 paper [5] on clinical application of the model, giving rise to the reasonable inference that the biopsychosocial model was a guide to clinical practice. However, as we went on to note in Sect. 1.2, there have been many developments in the intervening decades with more direct relevance to scientific con-tent and guiding clinical practice. There have been new research pro-grammes to investigate the causes of diseases and disease mechanisms, and technologies for prevention, early detection and treatment. These, in turn, have led to treatment guidelines for specific conditions at specific stages, to the whole apparatus of evidence-based clinical care, to be used alongside a thorough assessment of the individual case. The point is sim-ply that, given all this basic and clinical science of the last few decades, the biopsychosocial model cannot usefully be regarded as some additional statement of the science or as a tool to guide clinical decision-making.
It is true the model advises us to keep one’s mind open to the range of biopsychosocial factors, but the treatment guidelines and the science behind them already now say this, if applicable, and we don’t need a gen-eral model to repeat the fact—especially not to repeat it vaguely instead of paying close attention to the science of specific conditions and stages.
While this may be a solution for the biopsychosocial model of the vagueness problem, it works only, as we noted in section “So What’s the Point of a ‘General Model’?”, by raising the more fundamental ques-tion: what is the point of having a general model at all? We then located the task of the general model as defining biopsychosocial ontology and causation, in Sect. 1.3, noting the special need for this because of the deeply entrenched assumptions of physicalism, dualism and reductionism that have been so influential in the development of the life and human sciences. With these assumptions, only physical properties and causation appear real, while the mind is a non-causal epiphenomena, and social organisation and processes can hardly be comprehended at all. In short, the scientific and philosophical back story is more or less entirely anti-thetical to theorising biopsychosocial ontology and interactions. Hence the need for a new general theory for this purpose. We pursued this, tracking the science, in Chapters 2 and 3.
In Chapter 2 on biology we used the approach especially suited for the present purpose that relates biological processes to physics. Life forms do extraordinary things with energy, holding up the general direc-tion of the second law of thermodynamics, for a while, the key being control by genetic code, essentially prone to error, to doing it differently, making space for evolutionary diversification. The key ontological shift compared with physicalism is away from few primary physical qualities and laws, variations on the theme of energy and energy conservation, towards multiplicity and diversity of dynamical forms with their own dis-tinctive principles of change and causal interaction, all however retaining consistency with the physics of the matter. The corresponding key episte-mological shifts are from generality to specificity, simplicity to complex-ity, and from knowledge of inviolable facts to active knowing, something more like ‘trial and error’. Moving on from biology, the psychological and the social were considered in Chapter 3. The primary concept of the psychological is identified as agency. This connotes altogether: causation, in the sense of regulatory control, authorship, individual differences, and self-determination. Agency is thoroughly biological: it is embodied, and accordingly has to secure the conditions necessary for biological life, spe-cifically those related to maintaining appropriate energy differentials. At the same time, agency for us social beings needs recognition in the social group, and generally assumes a socio-political dimension, connoted by the related concept of autonomy. The primary function of the social is
identified in the model as the regulatory control of the distribution of resources necessary for biological life, but also of resources and opportu-nities for psychological development and cultivation of agency.
In this biopsychosocial theory, concepts of health and disease appear in prototypical form at the beginning, in the differences between sur-vival and non-sursur-vival of biological organisms, between a biological sys-tem’s working or breaking down. The basic facts of biological health and disease carry through into the biopsychosocial whole, being joined by concepts of psychological health and ill-health, related to agency, and concepts of psychosocial health and disadvantage, marked by exclusion from social relationships, resources and opportunities. Causal pathways run within and between all these systems and the many subsystems that serve them, in health and ill-health. The exact pathways and the size of effects vary with the health condition, its stage, and the challenges it pre-sents to the person as agent.
As well as major developments in the basic and clinical sciences since Engel’s original papers, there have been other major developments in dedicated models of health and disease and clinical practice. Three such have been mentioned so far in this chapter, Sect. 4.2: the social model of disability, which contests attribution of cause of activity limitations to the person rather than to the ill-resourced, socially excluding environment;
the model of patient-centred care, which locates the person as patient, their aims and values, at the centre of healthcare, and the Recovery model, which theorises the need of the person with a chronic health condition to recover their life notwithstanding. These dedicated models emphasise specific important aspects of healthcare that broadly relate to individual differences, the person, the broader social and political text, and managing with chronic conditions—typically with explicit con-trast with a perceived simple and over-simple ‘medical model’, with its focus on biological disease processes in the individual. In this sense, these models have taken up challenges and tasks of the sort that Engel identi-fied, but with more elaboration, depth and detail than the biopsychoso-cial model itself.
As proposed here, biopsychosocial theory and the biopsychosocial model define the conceptual foundations of a new approach to health, disease and healthcare, one that responds to the accumulating evidence implicating many and diverse processes of kinds indicated by the name, and more besides, particularly the physics and chemistry of our bodies
and the environment, at one end, and social and economic policy at the other. It is more general than the science of specifics, or single dis-ciplines, or dedicated models of clinical care. It is more like a view of human nature, based in the current science, one that includes propensity to health and disease. As a view of human nature and its vulnerabilities, the biopsychosocial model is comparable to the biomedical model. The biomedical model has two versions however: the old version, running to approximately mid-twentieth century, assuming, as Engel saw, physicalist reductionism and dualism, the other brand new and going from strength to strength since, at the cutting edge of reconstructing the relationship between biology, physics and chemistry, and articulating new models involving not only the inviolable physics and chemistry of energy, but also vulnerable forms regulated to ends. The new research programmes have advanced biomedicine, but at a conceptual level they open up worlds beyond the biological to include the psychological and the social.
This conceptual opening up is of huge importance given that the con-ceptual foundations of health science and healthcare need to be able to comprehend and respond to all the new findings on psychosocial factors that have been accumulating over the past few decades, on the social determinants of health, the effectiveness of psychological and social treat-ments, and the increasing prevalence of long-term health conditions.
Biopsychosocial theory, incorporating the psychosocial and the politi-cal, also involves morality. The biopsychosocial model of health and dis-ease has conceptual connections with bioethics. This is a contrast with the biomedical model, in either its old or new forms. To the extent that the biomedical model embraced physicalist reductionism, it was not enti-tled to any normative concepts, not even the difference between health and disease, and definitely not morals. Normativity has no place in phys-ics and chemistry. The new biomedical model that invokes regulatory control mechanisms has normativity, but so far restricted to internal somatic systems and does not yet comprehend the whole human being as an agent in the interpersonal, socio-political world. To have this reach, the biopsychosocial model is required, and the term ‘bioethics’ could be expanded to ‘biopsychosocial ethics’. At the foundational level, all normativity is interconnected. The 4 principles of bioethics laid out by Beauchamp and Childress [57] employ terms and relations that are foun-dational in biopsychosocial theory: autonomy of the person, harm and benefits to the person, social distribution of resources. The biopsycho-social theory does not resolve ethical disputes but indicates their terms
